Effectiveness of aquatic and non-aquatic lower limb

ISSN 1413-3555
Original Article
Rev Bras Fisioter, São Carlos, v. 14, n. 3, p. 229-36, May/June 2010
Revista Brasileira de Fisioterapia
©
Effectiveness of aquatic and non-aquatic lower
limb muscles endurance training in the static
and dynamic balance of elderly people
Efetividade do treinamento de resistência à fadiga dos músculos dos membros
inferiores dentro e fora d’água no equilíbrio estático e dinâmico de idosos
Núbia C. P. Avelar, Alessandra C. Bastone, Marcus A. Alcântara, Wellington F. Gomes
Abstract
Background: Aging compromises the ability of the central nervous system to maintain body balance and reduces the capacity for
adaptive reactions. To prevent falls, the reception conditions for sensory information need to be improved. Objectives: To evaluate
the impact of a structured aquatic and a non-aquatic exercise program for lower-limb muscle endurance on the static and dynamic
balance of elderly people. Methods: This was a prospective randomized clinical study in which the variables were assessed before and
after the training program. Thirty-six elderly people were evaluated using four tests: the Berg Balance Scale, Dynamic Gait Index, gait
speed and tandem gait. The participants were randomized into three groups: aquatic exercise group, non-aquatic exercise group and
control group. The exercise groups underwent a program for lower-limb muscle endurance that consisted of 40-minute sessions twice a
week for six weeks. The participants were reevaluated after six weeks. The data were analyzed statistically using the univariate ANOVA
test for comparisons between the groups before and after the intervention. Results: The program for lower-limb muscle endurance
significantly increased balance (p<0.05) in the evaluation tests after the training program. Conclusion: The muscle endurance program
provided a significant improvement in static and dynamic balance among community-dwelling elderly people. It was also possible to
infer that this improvement occurred regardless of the environment, i.e. aquatic or non-aquatic.
Article registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) under the number ACTRN 12609000780257.
Key words: hydrotherapy; physical therapy; elderly people.
Resumo
Contextualização: O envelhecimento compromete a habilidade do sistema nervoso central (SNC) de realizar a manutenção do
equilíbrio corporal bem como diminui a capacidade das reações adaptativas. Para prevenir as quedas, é necessário aprimorar as
condições de recepção de informações sensoriais. Objetivos: Comparar o impacto de um programa estruturado de exercícios de
resistência muscular dos membros inferiores dentro e fora d’água no equilíbrio estático e dinâmico em idosos. Métodos: Trata-se de um
estudo clínico, prospectivo, aleatório, em que as variáveis utilizadas foram avaliadas antes e após o programa de treinamento. Foram
avaliados 36 idosos por meio de quatro testes: Escala de Equilíbrio de Berg, Dynamic Gait Index, velocidade da marcha, Marcha
Tandem. Posteriormente, houve a alocação dos voluntários em três grupos: grupo de exercício na piscina terapêutica, grupo de
exercício no solo e grupo controle. Os grupos de exercícios foram submetidos a um programa de resistência muscular dos membros
inferiores aplicado durante seis semanas, duas sessões semanais com 40 minutos de duração. Os voluntários foram reavaliados após
seis semanas. Os dados foram analisados estatisticamente pelo teste ANOVA univariada para comparação entre os três grupos antes
e após a intervenção. Resultados: O programa de resistência muscular dos membros inferiores promoveu aumento significativo do
equilíbrio dos idosos (p<0,05) nos testes avaliados após o programa de treinamento. Conclusão: O programa de resistência muscular
proporcionou uma melhora significativa no equilíbrio estático e dinâmico de idosos comunitários. Foi possível inferir também que essa
melhora ocorreu independentemente do meio em que o programa foi realizado, ou seja, se dentro ou fora d’água.
Artigo registrado no Australian New Zealand Clinical Trials Registry (ANZCTR) sob o número ACTRN 12609000780257.
Palavras-chave: hidroterapia; fisioterapia; idosos.
Received: 08/12/2008 – Revised: 14/06/2009 – Accepted: 18/08/2009
Physical Therapy Department, Universidade Federal dos Vales dos Jequitinhonha e Mucuri (UFVJM), Diamantina (MG), Brazil
Correspondence to: Wellington Fabiano Gomes, Rua da Glória, 187, Centro, CEP 39100-000, Diamantina (MG), Brazil, e-mail: [email protected]
229
Rev Bras Fisioter. 2010;14(3):229-36.
Núbia C. P. Avelar, Alessandra C. Bastone, Marcus A. Alcântara, Wellington F. Gomes
Introduction
Improvement of health conditions, increasing life expectancy worldwide and birth rate reductions have brought about
a proportional increase in the older population1-3. Ageing compromises the ability of the central nervous system to carry out
processing on the vestibular, visual and proprioceptive signals
that are responsible for the maintenance of body balance, as
well as reducing individuals’ capacity to come up with adaptive
reactions1. Postural instability is one of the main factors that
limit older individuals’ daily activities, and falling is the most
harmful consequence of this process, thereby limiting functional mobility and rendering older adults more dependent4.
In order to prevent falls, the conditions under which sensory information is received from the vestibular, visual and somatosensory systems need to be improved in such a way that
the muscles of the effector system are activated and balance is
stimulated5,6, one of the means adopted to promote such stimuli
is physical exercise7. This reduces the risk of falls among older
adults through enhancing coordination and balance8, increasing
the recruitment of motor neurons and boosting the resistance to
muscle fatigue and hypertrophy, particularly of type II fibers9.
Most studies in the literature have shown improvements
in older patients’ balance through multifactorial interventions,
including balance10,11, muscle endurance9,11 or muscle strengthening11-13 exercises, or an association between these8-10. Studies
that assess the effect of muscle endurance training alone on
balance are rare9,11.
Muscle endurance exercises may be carried out in an
aquatic environment, as well as on the floor9-11. Aquatic exercises make it possible to create situations of instability by using
effects such as turbulence, providing a great amount of sensory
information, which in turn promotes improvement in body
balance reactions14,15,17-20. On the other hand, exercises performed in a non-aquatic environment are closer to activities
of daily living activities, since they do not cancel out the force
of gravity9-13. However, there are no studies in the literature
comparing the effectiveness of muscle endurance training in
aquatic and non-aquatic environments. Hence, this study had
the objective of comparing the impact of structured exercise
programs to test lower-limb muscle endurance in aquatic and
non-aquatic environments, in situations of static and dynamic
balance, involving older adults.
Methods
This was a prospective, randomized clinical study in which
the variables used were evaluated before and after the training program. This study was conducted in accordance with
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Rev Bras Fisioter. 2010;14(3):229-36.
the ethical principles for research involving human beings,
as prescribed by Resolution 196/96 from the National Health
Board (Conselho Nacional de Saúde). It received approval from
the Research Ethics Committee of the Universidade Federal
dos Vales do Jequitinhonha e Mucuri (UFVJM), Diamantina
(MG), Brazil (protocol no. 020/08). The participants received
information about the study and signed a free and informed
consent statement.
A pilot study was carried out to check the feasibility of the
investigation and to monitor the entire data collection process.
The volunteers in this specific group (n=10) were not included
in the treatment together with the other subjects, and there
were no problems during the process.
Sample
The sample for this study was made up of elderly volunteers from the community, who lived in the city of Diamantina,
Minas Gerais, Brazil. They were recruited through the Family
Health Program (Programa de Saúde da Família – PSF).
All the selected participants met the following inclusion
requirements: 60 years of age or older, and able to perform the
Get Up and Go Test19. The exclusion criteria were: individuals
undergoing physical therapy treatments; those who had respiratory diseases or heart or metabolic diseases; those with a
cognitive deficit according to the Mini-Mental State Examination (MMSE)20; those who had contagious skin abnormalities;
those who were using lower limb prostheses; those who made
use of drugs or medicines that might interfere with balance
(nicotine, caffeine, alcohol, sedatives and tranquilizers); and
those who had no anal or vesical sphincter control.
The volunteers who fulfilled the inclusion criteria made
up the final sample (n=46), and these individuals were distributed randomly among the groups that were assigned to the
therapeutic pool intervention (n=14), non-aquatic intervention (n=15) and control group (n=17). The intervention groups
performed the protocol twice a week for six weeks, while the
control group did not have any specific kind of treatment, with
only a weekly follow-up by telephone.
Assessment instruments
•
Dynamic gait index (DGI) (Brazilian version): This is a
functional assessment test on mobility among elderly patients with balance impairments, which was validated by
Shumway-Cook and transculturally adapted for application
in Brazil2. The test is made up of 14 tasks, and each of them
is categorized on a five-point ordinal scale. It has the aim
of assessing and documenting patients’ capacity to modify
their gait according to changes in the demands of certain
Muscle endurance training and balance among elderly people
•
•
•
tasks. The maximum score is 24 points, and a score of 19 or
lower suggests a risk of falls2.
Berg Balance Scale: This is an instrument for functional assessment of balance that has been validated and adapted
transculturally for application in Brazil21-23. The test is made
up of 14 tasks and each them is categorized on a five-point
ordinal scale ranging from 0 (unable to perform the task)
to 4 (able to carry out the task independently), based on
the quality of the performance, need for assistance and
time taken to complete the task. The scores from the 14
tasks are summed to form a total score going from 0 to 56
points, such that the highest scores correlate with the best
performance.
Tandem gait test: This test assesses patients’ dynamic balance. They are required to walk in a straight line, such that
the heel of the non-dominant foot is placed in front of the
toes of the other foot. The performance in this test is interpreted as good when the subject is able to walk more than
ten steps in a straight line; the subject is considered to have
feelings of fear and uneasiness when he/she takes between
two and ten steps; and the performance is poor when less
than two steps are taken in a straight line24.
Gait speed test: the normal gait speed was measured
by using a digital stopwatch. The volunteers were told
to walk along a 10-meter path and the time taken was
recorded, although the first two and the last two meters were left out of the calculation, in order to exclude
speed variation during the acceleration and deceleration
phases, respectively. The gait speed was calculated by
dividing these 6-meters by the time taken to cover this
distance along the path25.
Procedures
The volunteers received a detailed explanation about the
objectives and procedures of the study and signed a free and informed consent statement. Clinical and demographic data were
collected by means of an evaluative questionnaire. The MMSE and
some physical tests, namely the DGI, Berg Balance Scale, Tandem
gait and gait speed tests, were applied to the participants.
The next step consisted of randomly distributing the volunteers into three groups: an intervention group that received
aquatic physical therapy treatment (AG), a non-aquatic intervention group (NAG) and a control group (CG). The appraisers
had no access to the allocation of the volunteers to the groups.
The AG underwent muscle endurance training in the physical
therapy pool, twice a week, for six weeks. The NAG underwent
muscle endurance training in the physical therapy gym twice a
week, for six weeks. The CG did not receive any kind of physical therapy intervention during the six weeks of the study. In
order to further ensure that the latter group’s condition was
maintained, weekly phone calls (six calls) were made to each
participant, in order to follow up their daily activities.
Intervention
The structured muscle endurance program for the lower
limbs consisted of a series of muscle endurance exercises for
the lower limbs, carried out twice a week, every other day, for
six weeks in a row. These exercises were similar for both the
non-aquatic and therapy pool groups, differing only in relation
to the environment in which they were being performed. The
program, with the positions and activities that were carried
out, is described below:
Phase I – warming up
Walking: gait with progressive speed, up to 3 minutes.
Stretching (the stretching positions were sustained for 30
seconds):
Stretching of the hamstring muscles
Position in the pool and on the floor: orthostatic position
with the back resting against the wall.
Activity in the pool: to lift one of the lower limbs, while
maintaining knee extension and ankle dorsiflexion.
Activity on the floor: to perform spinal flexion, while keeping the lower limbs stretched out.
Stretching of the rectus femoris and iliopsoas muscles
Position in the pool and on the floor: orthostatic position
with both hands resting on the edge of the pool or against the
wall, respectively.
Activity in the pool and on the floor: to perform knee flexion, sustaining it with the aid of the ipsilateral upper limb, in
association with hip extension.
Phase II – muscle endurance exercises
Exercise 1: endurance exercise for the anterior muscles of the
thigh
Position in the pool and on the floor: orthostatic position
with the back resting against the wall.
Activity in the pool and on land: to perform hip flexion with
knee extension (4x20).
Exercise 2: endurance exercise for the posterior muscles of
the thigh
Position in the pool and on the floor: orthostatic position
with the hands resting on the edge of the pool, or against the
wall, respectively.
231
Rev Bras Fisioter. 2010;14(3):229-36.
Núbia C. P. Avelar, Alessandra C. Bastone, Marcus A. Alcântara, Wellington F. Gomes
Activity in the pool and on the floor: to perform hip flexion
with knee extension, while keeping the spine straight (4x20).
Exercise 3: endurance exercise for the lateral muscles of the
thigh
Position in the pool and on the floor: orthostatic position,
perpendicular to the supporting edge, with the hands resting
on the edge of the pool or wall, respectively.
Activity in the pool and on the floor: to perform hip abduction, while avoiding any spinal movement (4x20).
Exercise 4: endurance exercise for the medial muscles of the
thigh
Position in the pool and on the floor: orthostatic position,
perpendicular to the supporting edge, with the hands resting
on the edge of the pool or wall, respectively.
Activity in the pool: to perform adduction (return from the abduction) of the hip, while avoiding any spinal movement (4x20).
Activity on the floor: to perform adduction beyond the median line, while preventing the spine from moving (4x20).
Exercise 5: endurance exercise for triple flexion of the lower
limbs
Position in the pool and on the floor: orthostatic position
with the back resting against the wall.
Activity in the pool and on the floor: to perform triple flexion of the hips, knees and ankles (4x20).
Exercise 6: endurance exercise for the plantar flexors
Position in the pool and on the floor: orthostatic position
facing the edge of the pool or wall, respectively, with support
only in the event of lack of balance.
Activity in the pool and on the floor: plantar flexion in association with knee extension (4x20).
Exercise 7: endurance exercise for dorsiflexors
Activity in the pool and on the floor: to perform gait while
standing on heels (three series lasting one minute each with a
30-second interval between them).
Phase III – cooling down
Walking
Activity in the pool and on the floor: gait with regressive
speed, for up to three minutes.
Statistical analysis
The SPSS 11.0 software was used to analyze the data. For
the quantitative variables, central tendency and variability
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Rev Bras Fisioter. 2010;14(3):229-36.
measurements (mean, median, SD, minimum and maximum)
were used. For the nominal variables, a frequency distribution table was produced. The Shapiro-Wilk test was applied
to investigate whether the data was normally distributed. For
multiple comparisons between the groups before and after the
intervention, we used the univariate ANOVA test with Tukey’s
post-hoc test to identify the differences between the groups. It
was decided to analyze the data by means of parametric analysis, because the data had normal distribution. Furthermore,
the Kruskal-Wallis test was used to compare the category variables of sex and incidence of falls between the groups. In all the
analyses, the significance level was set at 5%.
Results
Among the 46 older adults initially selected, 36 completed
the study and were reevaluated after six weeks. Two participants in the AG group had to discontinue their treatment due
to health problems; one in the NAG moved to another town,
and seven individuals in the CG abandoned the study.
The participants’ mean age was 69 years (SD=5.6; range
60–80) in the NAG, 68 years (SD=5.7; range 62–78) in the AG and
71 years (SD=3.9; range 65–78) in the CG. There was no significant age difference among the groups (p=0.402). The proportion
of male subjects was significantly larger in the AG, comprising
64% (p<0.05), whereas the NAG and CG consisted mainly of
female individuals (respectively, 83% and 70%). The AG and CG
reported greater incidence of falls; however, there was no statistically significant difference among the groups (p>0.05).
Figure 1 represents the test measurements: a) Berg Balance
Scale; b) DGI; c) Tandem gait; and d) Gait speed before and after
the intervention. No variables showed differences between the
groups before the intervention, thus indicating that the sample
was homogeneous (Table 1). After the intervention, only the
DGI and Berg variables showed significant differences between
the intervention groups and the CG (Table 2). There was no
significant difference between the therapies carried out in the
non-aquatic and aquatic environments (Figure 1).
Discussion
The objective of this study was to investigate whether a
lower-limb muscle strengthening program, conducted either
in an aquatic or in a non-aquatic environment, would be capable of improving older adults’ static and dynamic balance. In
order to test our hypothesis, we used exercises that were easy
to reproduce and to apply, with specifications relating to the
frequency and duration of each exercise. This makes it possible
Muscle endurance training and balance among elderly people
56
Berg Scale (Score)
A
54
52
**
**
**
Before intervention
After intervention
50
48
46
44
GW
B
DGI (Score)
25
*
****
GL
GC
*
20
Before intervention
After intervention
15
10
5
0
D
GW
GL
GC
10
Tandem Gait (nº pace)
C
8
Before intervention
After intervention
6
4
2
0
GW
GL
GC
2,5
Gait Velocity (m/s2)
to replicate this experiment in order to confirm the efficacy of
the muscle training program for the static and dynamic balance of older people.
The sample was made up mainly of older women with a
history of falls. This sample composition may be seen in several
other studies10,12,15,17,18,26,27, thereby corroborating the literature,
since functional limitations occur more frequently among
women, and they report suffering from a greater number of
chronic conditions28.
The results from the present investigation show that the
training proposed was capable of improving the static and
dynamic balance of older people. Likewise, other studies had
shown that muscle training has a positive impact on balance
among older adults8,9,11,13,18. Our training protocol had a frequency of twice a week, for a period of six straight weeks. There
is evidence that two or three times a week is a frequency that
results in significant improvements in muscle endurance, balance and functional performance, and it also reduces the number of falls8,25. In addition to this, the minimum duration of a
training program is thought to be between six and eight weeks,
i.e. the time needed to surmount the motor learning and neural adaptation phases, which are the phases mainly responsible
for the production of strength and endurance during the first
weeks of a training program25.
Several studies have used physical exercise to improve
older adults’ static and dynamic balance26-31. Ballard et al.32
looked into the effect of a program of exercises and measures
to reduce falling among 40 community-living older women.
The experimental group performed exercises in sessions that
lasted one hour, three times a week, for 15 weeks. Among
the activities, they underwent aerobic exercises and exercises to strengthen the lower limbs with elastic resistance.
The volunteers were evaluated on the Berg Balance Scale,
to measure their balance, and by means of a test referred to
as Wall-sit, to measure their muscle endurance. The results
from their study showed that their muscle endurance had
increased significantly and that the participants’ body balance had improved.
The Berg Balance Scale is an instrument that is very frequently used both in clinical practice and in research work
to assess dynamic and static balance. In the present study,
we observed that the groups that underwent the muscle endurance test improved their mean score on this scale. Similar data, in which it was observed that training and balance
programs improve the scores on this scale, are found in the
literature11,14,30-32. In the experiment conducted by Hess and
Woollacott33, a muscle endurance program lasting only ten
weeks provided an improvement in older adults’ balance that
was made evident by significantly higher scores on the Berg
Balance Scale.
2
Before intervention
After intervention
1,5
1
0,5
0
GW
GL
GC
Figure 1. Medium values of the static and dynamic balance appraised
for the instruments: a) Berg Scale; b) DGI; c) Tandem Gait; d) Gait
Velocity in elderly in Water Group (GW), Land Group (GL) and Control
Group (GC).
In the present study, there were no improvements in
the older people’s static or dynamic balance according to
the Tandem gait test. As reported by Pereira34, the tandem
gait test is one in which the elderly population has a weak
performance. Therefore, we believe that it was not sensitive
233
Rev Bras Fisioter. 2010;14(3):229-36.
Núbia C. P. Avelar, Alessandra C. Bastone, Marcus A. Alcântara, Wellington F. Gomes
Table 1. Tests Post Hoc among the groups in the moment before the intervention (n=36).
Dependent variable
DGI
Tukey
I
II
Pattern error
Land
Water
Cont
Land
Cont
Land
Water
Water
Cont
Land
Cont
Land
Water
Water
Cont
Land
Cont
Land
Water
Water
Cont
Land
Cont
Land
Water
1.59
1.68
1.59
1.73
1.68
1.73
1.88
1.98
1.88
2.05
1.98
2.05
1.53
1.61
1.53
1.66
1.61
1.66
0.16
0.17
0.16
0.17
0.17
0.17
Water
Cont
Berg Sacle
Tukey
Land
Water
Cont
Tandem Gait
Tukey
Land
Water
Cont
Gait velocity
Tukey
Land
Water
Cont
Trust interval
Inf
-3.97
-1.76
-3.85
-1.84
-6.47
-6.67
-5.35
-2.91
-3.89
-2.35
-6.82
-7.71
-4.15
-3.02
-3.34
-2.75
-4.87
-5.41
-0.29
-0.31
-0.49
-0.41
-0.53
-0.44
Sup
3.85
6.47
3.97
6.67
1.76
1.84
3.89
6.82
5.35
7.71
2.91
2.35
3.34
4.87
4.15
5.41
3.02
2.75
0.49
0.53
0.29
0.44
0.31
0.41
Sig
0.999
0.350
0.999
0.356
0.350
0.356
0.922
0.590
0.922
0.400
0.590
0.400
0.962
0.833
0.962
0.704
0.833
0.704
0.810
0.792
0.810
0.997
0.792
0.997
Table 2. Tests Post Hoc among the groups in the moment after the intervention (n=36).
Dependent variable
DGI
Tukey
I
II
Pattern error
Land
Water
Cont
Land
Cont
Land
Water
Water
Cont
Land
Cont
Land
Water
Water
Cont
Land
Cont
Land
Water
Water
Cont
Land
Cont
Land
Water
1.13
1.19*
1.13
1.23*
1.19*
1.23*
1.61
1.69*
1.61
1.75*
1.69*
1.75*
1.31
1.38
1.31
1.43
1.38
1.43
0.18
0.20
0.18
0.20
0.20
0.20
Water
Cont
Berg Scale
Tukey
Land
Water
Cont
Tandem Gait
Tukey
Land
Water
Cont
Gait velocity
Tukey
Land
Water
Cont
234
Rev Bras Fisioter. 2010;14(3):229-36.
Trust interval
Inf
Sup
-3.05
2.50
1.62
7.46
-2.50
3.05
1.79
7.84
-7.46
-1.62
-7.84
-1.79
-4.37
3.54
1.13
9.47
-3.54
4.37
1.41
10.02
-9.47
-1.13
-10.02
-1.41
-4.11
2.32
-1.63
5.14
-2.32
4.11
-0.85
6.15
-5.14
1.63
-6.15
0.85
-0.21
0.70
-0.12
0.86
-0.70
0.21
-0.38
0.63
-0.86
0.12
-0.63
0.38
Sig
0.968
0.002
0.968
0.001
0.002
0.001
0.964
0.010
0.964
0.007
0.010
0.007
0.776
0.420
0.776
0.168
0.420
0.168
0.389
0.169
0.389
0.814
0.169
0.814
Muscle endurance training and balance among elderly people
enough to detect any improvements in the body balance of
these older adults.
The results from this study showed that the training protocol was not capable of improving the volunteers’ gait speed.
Our finding contrasts with studies in the recent literature25,35.
Britto et al.35 observed a significant improvement in individuals’ gait speed and balance after eight weeks of aerobic training and muscle endurance exercises. However, our endurance
training program prioritized training at slow motion speed,
whereas static balance calls for quick muscle contractions.
We also observed a significant increase in the static and
dynamic balance of the older adults who underwent the training protocols in the therapy pool. There is a growing trend
within the clinical environment to indicate aquatic exercises
for individuals who are afraid of, or who are at risk of falling13-17.
Resende, Rassi and Viana14 implemented a program of aquatic
physical therapy for older women, lasting for 12 weeks, twice a
week. The program, which was intended to improve balance,
included activities for adaptation to the aquatic environment,
hydrokinesiotherapy and aquatic exercises that defied balance.
The results from their study suggested that the program of
aquatic physical therapy exercises provided an increase in balance and a reduction in the risk of falls among older women.
We did not observe any significant differences in balance
improvement between the intervention groups in the aquatic
and non-aquatic environments. This result differs from what
was found by Lund et al.13, who compared the efficacy of
aquatic and non-aquatic exercise programs on the body balance of elderly patients and observed that the aquatic exercises
were significantly better for their balance than were the nonaquatic exercises. Nevertheless, it is important to highlight
that the subjects of that study suffered from osteoarthritis in
their knees, thus differing from our sample.
Although our sample was small, it showed that a program
of exercises to develop endurance of the lower limb muscles,
both in aquatic and in non-aquatic environments, provided a
significant improvement in the static and dynamic movement
of these community-living elderly people. Therefore, this endurance protocol may be used to improve the static and dynamic
balance of older adults. Moreover, it can be concluded that
aquatic muscle endurance training may be used as an alternative to conventional physical therapy treatment.
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